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Updated: Jan 23 2024

Claw Toe

Images photo_moved.jpg toe.jpg toe_moved.jpg osteotomy.jpg
  • summary
    • Claw toe is a lesser toe deformity characterized by MTP hyperextension and resulting PIP and DIP flexion.
    • Diagnosis is made clinically with presence of MTP hyperextension, PIP flexion and DIP flexion of a lesser toe.
    • Treatment is a trial of nonoperative management with shoe modification and taping. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations. 
  • Epidemiology
    • Anatomic location
      • typically involves multiple toes
      • often bilateral
  • Etiology
    • Pathophysiology
      • MTP hyperextension is the primary pathology
        • chronic MTP hyperextension leads to unopposed flexion of the DIP and PIP by FDL
        • analogous to intrinsic minus deformity in the hand
      • the MTP plantar plate becomes insufficient over time
      • base of proximal phalanx translates dorsally
      • interossei and lumbricals move dorsally
        • shifts flexion moment arm to the wrong side of the center of rotation
    • Cause
      • synovitis is the most common cause
      • trauma
      • delayed or missed compartment syndrome involving the deep posterior compartment of the leg or foot
    • Associated conditions
      • cavus deformity
      • neuromuscular disease affecting intrinsic and extrinsic muscle balance
        • clawing of all 4 lesser toes implicates a neurologic abnormality
      • inflammatory arthropathies
        • lead to soft tissue structure attenuation and MTP joint instability
  • Classification
      • Claw toe vs. Hammer toe vs. Mallet toe
      • Claw Toe
      • Hammer Toe
      • Mallet toe
      • DIP
      • Flexion
      • Extension
      • Flexion
      • PIP
      • Flexion
      • Flexion
      • Normal
      • MTP
      • Hyperextension
      • Slight extension
      • Normal
  • Presentation
    • Symptoms
      • pain at the level of the unstable MTP joint
      • metatarsalgia
    • Physical exam
      • inspection & palpation
        • claw-type deformity of the toe is present
        • depressed metatarsal head with callus formation and tenderness
        • flexed IP joints with callosities and tenderness
  • Treatment
    • Nonoperative
      • taping and shoe modification
        • indications
          • first line of treatment
        • techniques
          • provide adequate plantar padding using metatarsal and/or crest pads or orthotics to offload plantarly-subluxed metatarsal heads
          • wear a shoe with a high toe box
          • use a sling to hold the proximal phalanx parallel to the ground
    • Operative
      • EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer (Girdlestone)
        • indications
          • painful, flexible deformities without contractures
          • ulcerations caused by shoe wear
      • Girdlestone (above), MTP capsulectomy, and proximal phalanx head and neck resection
        • indications
          • fixed contracture
      • Girdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy)
        • indications
          • claw toe deformity of all four lesser toes
        • technique
          • oblique shortening osteotomy
          • translates metatarsal head proximal and plantar
      • Isolated FDL tenotomy
        • indications
          • flexible deformity in a diabetic patient with tip-of-toe ulceration without evidence of infection
  • Complications
    • Floating toe
      • most common complication of a Weil osteotomy
      • caused by intrinsics migrating dorsal to the joint and acting as MTP extensors
    • Recurrence
      • caused by persistent plantar plate dysfunction
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